HEART FAILURE   18A

A 75-year-old man with a history of coronary artery disease (CAD) and multiple previous myocardial infarctions (MIs) presents to his primary care provider with increasing shortness of breath. The patient’s exercise tolerance has gone from walking 10 blocks without stopping to needing to catch his breath after walking across the room. He can no longer lie flat at night and uses four pillows to prop himself up in bed. On physical examination, he has bilateral crackles halfway up his lung fields, his jugular venous pulsations (JVPs) are elevated, and his lower extremities have pitting edema.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Elderly man with CAD and previous MIs; shortness of breath; orthopnea; lung crackles from left-sided failure; elevated JVP and lower extremity edema from right-sided failure

How to think through: Heart failure (HF) is a prevalent, important syndrome. Prompt diagnosis and effective management improve morbidity, mortality, and quality of life. As in this case, HF diagnosis typically begins with a complaint of undifferentiated dyspnea on exertion. This patient also describes orthopnea. What additional symptoms also should be elicited? (Exertional chest pain, paroxysmal nocturnal dyspnea, lower extremity edema, syncope or presyncope, palpitations.) What cardiac pathologies can produce HF (as well as the physical examination signs found in this patient)? (Impaired systolic function, impaired diastolic function, and valvular disease.) What physical examination sign should be present with systolic and diastolic dysfunction? (Enlarged, sustained, displaced point of maximal impulse [PMI] at the apex.) After a diagnosis of HF is made, the underlying cause should be identified. In this case, the patient has known CAD, and an echocardiogram or nuclear imaging study may show wall motion abnormalities consistent with ischemia or infarction. What medication classes improve mortality and should be added if not already part of his regimen? (Angiotensin-converting enzyme [ACE] inhibitor, β-blocker, aldosterone receptor blocker.) A loop diuretic should be started for symptomatic relief immediately after assessment of electrolytes and renal function. If this patient proves to have an ejection fraction of less than 35%, what other interventions might help? (Implantable cardiac defibrillator improves mortality. Biventricular pacing can significantly improve symptoms and systolic function in some patients.)

HEART FAILURE   18B

What are the essentials of diagnosis and general considerations regarding heart failure?

Essentials of Diagnosis

Symptoms of left ventricular (LV) or right ventricular (RV) HF

General Considerations

HF occurs as a result of impaired cardiac output or diastolic dysfunction with fluid retention.

Acute exacerbations may be caused by excessive salt intake, arrhythmias, or pulmonary emboli.

High-output HF is caused by thyrotoxicosis, beriberi, severe anemia, or arteriovenous shunting.

Systolic dysfunction is caused by MI, ethanol abuse, longstanding hypertension, viral myocarditis (including HIV), or Chagas disease or is idiopathic.

Diastolic dysfunction is associated with abnormal filling of a (“stiff”) LV caused by chronic hypertension, LV hypertrophy, and diabetes mellitus.

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